Pretest for the Medical Office VE survey

Pilot Test of the Proposed Value and Efficiency Surveys and Communicating About Value Checklist

Documents and Forms

Document Name Document Type
Form Form #4 Pretest for the Medical Office VE survey Form and Instruction
Form #4 Pretest Survey for Medical Office VE Survey Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx Form and Instruction
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey IC Document

Information Collection (IC) Details

IC Title:	Pretest for the Medical Office VE survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #4	Pretest Survey for Medical Office VE Survey	Attachment D - Pretest Survey for Medical Office VE Survey_1-17-13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 504	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	504	504
Annual IC Time Burden (Hours)	126	126
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey	Attachment H - Pretest Cover Letter and Reminder Notice for Medical Office VE Survey.docx	04/18/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.